The worrying signs were all there: fatigue, high fever, inability to taste or smell.

Even so, Ahmed *, a salesman at a hardware store in suburban Damascus, has never considered getting tested for coronavirus or going to the hospital. The first option was prohibitive, he thought; the second dangerous.

“I was afraid of being quarantined and not receiving adequate medical care,” the 20-year-old said, referring to the Syrian government-run facilities where COVID-19 patients are being sent.

Instead, Ahmed confined himself to his room, sought medical advice on Facebook, and called a local doctor for advice. Neither he nor anyone he had contact with was tested. “I couldn’t afford it,” he told Al Jazeera over the phone, explaining that it cost him 126,000 Syrian pounds ($ 246) more than his monthly salary.

Ahmed’s suspected coronavirus infection is believed to be among the thousands of cases that go undetected in the areas held by the Syrian government in late July. Official data assume 4,366 confirmed COVID-19 infections with 205 deaths. However, several doctors, local residents and health professionals who spoke with Al Jazeera inside and outside the war-torn country say these numbers do not reflect the true extent of the coronavirus outbreak.

“There is a big gap between the actual numbers [of cases and deaths] and the one announced by the government because of a lack of resources and capacity to admit patients, but also because it wants to mitigate unexpected effects of the pandemic such as social unrest, “said Zaki Mehchy, Senior Consulting Fellow in London at Chatham House and co-founder of Syrian Center for Policy Research, Al Jazeera said.

“People prefer to die”

With a collapsed health system, a battered economy, and severe shortages of doctors and nurses due to doctors fleeing the brutal war in Syria, authorities face an uphill battle to control the spread of COVID-19.

Chronic shortages of medical equipment and supplies – along with poor conditions in quarantine facilities, the need to earn a living after more than nine years of conflict, and deep distrust of government institutions – have resulted in many suspicious patients with no respiratory-related symptoms have reported illness.

To fill these gaps, coronavirus-related Facebook groups have sprung up online where doctors offer medical advice – just like companies that rent oxygen tanks to patients for home use.

“People would rather die than go to the hospital,” Moustafa *, a doctor who works in a hospital in Damascus, told Al Jazeera on the phone.

He said he was often contacted by people seeking medical advice but could not afford protective equipment to visit them in person. A good quality mask that should be changed every day costs around 5,000 Syrian pounds ($ 10).

“That’s too much for me,” said Moustafa, who makes Syrian pounds 96,000 ($ 188) a month. “Can you imagine? A doctor who cannot afford to buy a good mask?”

“Only formalities”

The Syrian economy has been in freefall for the past few months, buckling under the weight of the country’s longstanding conflict and the impact of a dollar liquidity crisis next door in Lebanon. The financial turmoil has been exacerbated by a sharp fall in the value of the Syrian pound, which has made life even harder for millions of suffering Syrians who live on daily wages.

With more than 80 percent of the population below the poverty line, the rise in the price of basic commodities sparked sporadic protests during the Syrian summer as a new wave of United States sanctions put pressure on the crippled economy.

“The compulsory and unfair economic sanctions have impaired the capacities of many essential services, especially the health sector,” said Syrian Minister of Health Nizar Yazigi at a virtual meeting of the World Health Organization (WHO) in May, referring to the punishment of economic measures by Western countries.

In view of the deteriorating economic outlook, critics believe that the government has been too slow to introduce measures to contain coronavirus – and too quickly to abolish them. In May, despite a surge in infections, a month after businesses and public markets reopened, authorities lifted a two-month curfew and allowed traffic between government-held provinces. The mosques also reopened that same month, while students returned to classrooms on September 13th.

Students wearing protective face masks sit in a classroom as the school year begins in Damascus, Syria amid concerns over the spread of coronavirus disease [File: Yamam Al Shaar/Reuters]“The Ministry of Health only takes on formalities, no [real] Measures have been adopted [to curb the spread of coronavirus], especially now, “said Jamal *, another doctor at a Damascus clinic, reiterating similar worrying calls after a reported increase in the number of coronavirus cases and deaths in August.

While it’s extremely difficult to get precise data on the extent of the outbreak, a group of researchers at Imperial College London warned last month that Damascus only reported an estimated 1.25 percent of COVID-19 deaths, with up to 4,380 feared deaths were undetected as of September 2.

“Given that Damascus probably has the most robust surveillance in Syria, these results suggest that other regions of the country may have similar or worse death rates from COVID-19,” the researchers said.

In the city of Aleppo, the impoverished family of a man in his sixties who contracted coronavirus in August hesitantly decided to take him to Aleppo University Hospital. “Nobody trusts hospitals in Aleppo. Everyone knows that a coronavirus patient does not make it when he comes in, “said Khalil *, the man’s nephew.

At the crowded facility, Khalil said a paramedic had told his cousin, “You have to wait if any of the [other] Patients die; only in that case would your father be admitted. “Two days later the man died at home.

“Like a prison”

Meanwhile, underserved medical professionals say they must perform their duties under the watchful eye of high-performing security services roaming government health facilities.

Some say this is another deterrent for patients who are already unwilling to seek treatment in a country where there is great fear of the state apparatus and critical discussions about how to deal with the pandemic are seen as a threat to a government who is determined to convey a message of control.

“The hospital is like a prison: you can see people from the secret service, they check everything you do and say,” said Moustafa. “We have to hide everything so as not to talk about anything [related to COVID-19]. ”

Jamal said, “Patients arrive at the hospital on their last breath.”

“These cases require equipment that hospitals don’t have and people know it,” he added on the phone, noting that the government lacks the resources to take preventive measures and cannot treat or test patients.

“A million other reasons to die”

To help manage the crisis in government-controlled areas, WHO has set up five testing facilities – in the capital, rural Damascus, Aleppo, Homs and Latakia – that perform up to 1,000 coronavirus tests every day .

But according to Akjemal Magtymova, WHO’s Syria representative, this is not enough.

“Even if I could discover tens of thousands more cases, what do I do if we don’t have the resources to cure them?” Magtymova asked, a note of desperation in her voice.

According to the Global Health Department, only half of the country’s 113 public hospitals were fully functional by the end of June. There are fewer than three beds available for every 10,000 people – three times less than according to international standards.

Even more alarming for Magtymova, however, is the shortage of medical professionals. A staggering 70 percent of them have left the country since the war began in 2011, according to a United Nations report released in March.

“One of my biggest concerns is that we are working with a very limited number of healthcare workers who are at high risk of infection,” she told Al Jazeera.

“We are expecting a new wave – we need to see if these children return [from school] for her extended family ”, Magtymova emphasized that the transmission rate was not as high as in August, but the situation was still“ very fragile ”in view of the worsening economic problems.

“The people are starving; 9.3 million are food unsafe and depend on a daily wage, ”said Magtymova. “Why should you declare yourself sick and isolate yourself?”

Mustafa agreed: “This is not just about COVID-19, this is the least fear we have. Here one can die from COVID-19 for a million other reasons. “

  • Respondents asked to change their real names for security reasons.